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a Applications Will Be Processed When S!Up. m .Rd Properly Completed. Be Sure To Sign The Application. <br />KrOLICATIONON <br />(For Non -Transferable, Revocable, and Suspendable) <br />ENVIRON MENTAL HEALTH PERMIT SEPTAGE <br />+u 4- f LIQUID WASTE <br />i! <br />Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br />y Business Name (DBA)—WDN V_rtJG4NEr,-_,C�S4Ilk)'C. Address <br />z Owner Address <br />a <br />Firm Partners, Addresses and Telephone Numbers <br />RE Business Telephone No. I' 4""""t03�-' Emergency Telephone No. <br />Contractor Licence No. IM <br />dX Applicants Name (Print) IM �� CRANCE W N C" Title <br />i <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) I <br />Serial No. �M CAL. License No. <br />Capacity .. IM Gal., Weights & Measures No. <br />Equipment Parking Address �M <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />No, of Chemical Toilets Stored <br />3, yea PERCOLATION TEST <br />R.S. or R.C.E. Name .1C* CtimNCr— WONG" R.S. or R.C.E. No. <br />Test Location 4BBC IM 1N• K0 JW— O D Test Date/Time <br />° 4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner i� Address <br />❑ SEPTIC TANK ❑ CESSPIOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br />11 PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction it Disposal Site <br />No. of Units A Equipment Storage/Cleaning Location($) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />II <br />Date 'W W ftK' <br />CAL. License Renewal No <br />v Pct u Ii <br />i - <br />Plant <br />Plant <br />7. ❑ <br />SIZE: <br />❑ DR <br />APPLI <br />F <br />I v9 <br />❑ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />Location <br />Capacity N No. Units Served <br />LAUNDRY For July 1, Sig <br />30, 19 <br />❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />Y CLEANING, Chemicals Used/Amount/Mo. ; <br />I hereby certify that I have prepared this application and tha tZn <br />ork will be done in accordance with San Joaquin County <br />Ilk <br />ordinances, state laws, and rules an g 1 f the San Local Health District. <br />I <br />CANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY I. <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ nuary ceived By January 31 ❑ July i & Received By July 31 <br />I.< <br />�E_ REMIT rt <br />-BASE EXPLANATION BILLING REMITTA $ AMOUNT DUE CHECKED Ij <br />II DATE T REMITTED AMOUNT 3 <br />is <br />FEE Jk `r OBJ l <br />LESS <br />PRORATION ` - <br />PLUS R <br />PENALTY R <br />OTHER Ii <br />OTHER <br />/ <br />Receiot No, Permit No. Issuance Date ailed De ivered �1J <br />Received Date <br />APPLICANT—RETURN ALL COPIES To: <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON-AVe-,11 ', Box 2004 STOCKTON,.CA 95xo1 <br />Received Date <br />APPLICANT—RETURN ALL COPIES To: <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON-AVe-,11 ', Box 2004 STOCKTON,.CA 95xo1 <br />